Complaint·March 12, 2025

As part of the investigation, LPA interviewed the administrator, the maintenance director, and the resident care coordinator. According to the administrator, she was notified at 5pm that R1 was missing, the facility immediately conducted a search inside and outside of the facility, viewed the camera footage, reported it to the local police department where a silver alert was activated, and reported it to R1’s responsible party. The administrator stated that R1 was found in a locked empty room that was next to R1’s room and the room was being prepared by the maintenance staff for new admission. The administrator stated that when a room is being prepared for new admissions, it should be closed when it’s not being worked on to avoid residents entering it. The administrator acknowledged that R1 would have been found a lot sooner had the staff search all the rooms on the 3rd floor. LPA interviewed the maintenance director who stated that the day prior to the incident, he was getting the room ready for new admission and after painting the room, he realized that the door lock was broken but it was too late to bring it to the shop and fix it, so he left it open instead of closing it. According to the maintenance director, this was not endorsed to facility staff resulting staff was unaware that the empty room was open and R1 wandered inside, shut the door as the room was next to R1's room. LPA interviewed the resident care coordinator who validated the information above and stated that R1 has a tendency of shutting the door after entering his/he room. Therefore, R1 mistakenly entered the empty room, shut the door and was not able to open it back up because of the broken lock. Based on the documents provided by the facility, the Elopement /Missing Resident Policy 404 indicated that upon the discovery that a resident is thought to be missing, community team members will activate and follow the Missing Resident- Immediate Action Plan Form 405a and on the Form 405a, it indicated that within 5-10 minutes, assign staff to search unit. After the investigation, this allegation is substantiated as the staff did not followed the protocols on the Action Plan Form 405a and search the unit/room on the floor and the director failed to endorse to staff that the empty room was left open resulting R1 being locked in a room with a broken door for many hours. Based on interviews, and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator; a copy is provided with Appeal Rights provided.